Not only can marital conflict disrupt the family system, but it also poses serious problems to couples’ emotional-social development and subsequent marital adjustment (1). It can be expected that society will make progress when the family institution is functioning efficiently (2). Therefore, the existence of an intimate marital relationship, in which couples show affection and love to each other, is an indicator of a rich social life (3).

     One of the factors affecting marital satisfaction is marital intimacy which is recognized as one of the emotional needs of couples strengthening their loving relationship (4). Marital intimacy is a broad concept encompassing emotional closeness, shared pleasurable activities, satisfying and intimate sexual relationships, as well as sharing values, innermost feelings, and thoughts without any intimidation.

     Couples who enjoy a high level of marital intimacy can effectively communicate their needs in their relationships and easily deal with the emotions and opinions of their spouses (5). In his research, Bagarozi (2014) referred to couple intimacy as the most important factor in building a long-lasting marriage (6). In fact, intimacy plays a peculiar role in bringing satisfaction or dissatisfaction to couples since it strengthens the couple's commitment to the relationship and predicts relationship compatibility and happiness (7)

     On the other hand, marital satisfaction mirrors satisfaction with family life, and family satisfaction, in turn, implies life satisfaction. Consequently, it will promote the development, excellence, as well as material and spiritual progress of society. Marital satisfaction can be deemed as a psychological situation that does not develop automatically; however, both parties should put in a great deal of effort.  In the early years after the marriage, marital satisfaction is very unstable and the relationships are at serious risk (8).

     It can be argued that marital satisfaction is a gradual process that takes place over a couple's life course. It requires the recognition of personality traits, the provision of behavioral rules, and the development of communication patterns. Accordingly, it can be stated that satisfied couples concur with each other in various areas of life (9). In fact, satisfaction is an attitude variable which is considered an individual characteristic of couples; moreover, it is one of the most important and effective factors in the maintenance of a successful, healthy, and happy life (10).

     The use of psychological and non-pharmacological interventions is of paramount importance in the improvement of marriage functions. Numerous theories have been proposed to reduce marital conflicts and increase intimacy and marital satisfaction. In this regard, Glaser's reality therapy is a widely accepted approach that puts a special emphasis on a loving and intimate relationship and has been very popular in Iran.

      In the late 1950s and early 1960s, Glasser proposed reality therapy as a new way to help clients recognize behaviors that prevent them from reaching their goals. This approach is based on self or personal assessment that can be used in most human relationships, including parent-child relationships, husband and wife, employer and employee, and clients and therapists, as well as the self-relationship (11).

     Reality therapy encompasses some techniques which help people shift away from dysfunctional behaviors to efficient practices, from detrimental choices to wise ones, and above all else, from an unhealthy way of life to a glamorous lifestyle. It is the same as other psychological approaches which adopt special methods to change clients’ behavior (12). This method emphasizes reality and responsibility acceptance, the recognition of basic needs, moral judgment, centering on the present moment, internal control, and the development of a true identity that is directly linked to self-esteem.

      Glasser's choice theory is one of the most common therapeutic interventions in the field of cognitive psychology in describing human beings, determining behavioral rules, and achieving satisfaction, happiness, and success (12). In choice theory, the behavior is made up of four components, namely thinking, acting, feeling, and physiology. Individuals have direct control over the two components of thinking and acting and indirectly over the two components of feeling and physiology (13).

     Based on choice theory, people often make use of seven deadly habits of external control, including blaming, criticizing, nagging, threatening, complaining, punishing, and bribing. The replacement of these deadly habits with seven caring habits exacerbates spouses’ problems and improves their relationships. The seven caring habits include listening, supporting, encouraging, respecting, trusting, accepting, and negotiating differences (14).

     The strength of choice theory lies in its capability to help couples create a happy, long-lasting marriage. Therefore, the seven deadly habits should be avoided before taking any measures since these habits will detach the couple and add to their problems. Subsequently, one or more caring habits should be developed to resolve couple conflicts. The mere solution to marital problems is compassionate negotiation or the use of choice theory language. In a conversation based on choice theory, each party can suggest effective solutions to the problem.

     Such a conversation is called a lossless conversation, and both parties are considered winners. In this kind of negotiation, neither side puts extra pressure on the other party to gain more than their fair share (11). Mirzania et al. (2018) conducted a study entitled “Effectiveness of reality therapy based on choice theory on increased marital satisfaction and sexual self-esteem and reduced marital conflicts of women seeking divorce”. They reported that reality therapy based on choice theory significantly increased marital satisfaction and sexual self-esteem and reduced marital conflicts of women seeking a divorce (15).

     In a similar vein, Fathollahzadeh et al. (2017) examined the effectiveness of enriching marital life based on the choice theory on the quality of marital relationships and couple intimacy. The results of the mentioned study pointed to a significant difference between the performance of experimental and control groups in terms of the quality of marital relationships and couple intimacy in the post-test phase and after one month of follow-up (16). In general, Glasser's theory of choice in reality therapy is one of the most effective methods to solve problems, achieve intimacy and marital satisfaction, and recognize and manage the factors affecting marital success.

     The adverse effect of behavioral and communication problems is one of the leading factors affecting the growing trend of divorce in the country.  It highlights the importance of recognizing and seeking effective solutions to increase intimacy, deepen couple relationship, increase marital satisfaction, and seek new ways to research into couple conflicts are some of the reasons emphasizing the importance and necessity of the present study.

     With this background in mind, the current study aimed to investigate the effectiveness of reality therapy based on choice theory on intimacy and marital satisfaction in couples referring to Ahwaz psychological counseling centers and the research question was whether reality therapy based on choice theory is effective on marital intimacy and satisfaction in couples referring to Ahwaz counseling centers?

Materials and Methods

The present study was pretest-posttest control group design. The statistical population of the present study included all couples referring to Ahvaz Psychological Counseling Centers in 20018. A number of 40 couples who had a below-average score in intimacy and marital satisfaction based on the applied questionnaires were selected as the research participants based on inclusion and exclusion criteria. They were then randomly assigned to either the control group or the experimental group (n=20 in each group).

Based on J Gall & R Borg, 15 subjects are suggested for each experimental group in experimental and quasi-experimental research. Nonetheless, in the current study, to consider sample attrition and increase the external validity of the results, the sample size was determined as 20 participants. They were selected by convenience sampling method based on inclusion and exclusion criteria and were then assigned to two experimental groups (17).

After selecting the couples who referred to Ahvaz Counseling Centers, they were tested under the same conditions. Thereafter, the experimental group underwent reality therapy intervention based on the choice theory, while the control group did not receive any intervention. The inclusion criteria entailed: 1) no history of drug abuse, 2) no previous divorce experience, 3) no divorce petition, and 4) the absence of any physical or psychological illnesses. On the other hand, the exclusion criteria included: 1) Non-attendance in the intervention program for more than two sessions, 2) non-reception of a simultaneous treatment, and 3) non-use of any specific medication.

Before the application of the intervention protocol, the researchers explained the purpose of the study. In addition, the ethical principles for medical research involving human subjects were adhered to. Since our research method was couple therapy, the couples underwent interventions simultaneously. Therefore, the participants were consulted by the counseling center therapist in a group, and the session was also managed by the therapist.

It is worth noting that no teaching aid was used. In practical terms, the teaching method was interactive, meaning both lectures and group discussions. Depending on the topic of discussion, 15 min was allocated to each couple, and the rest of the time was assigned to the therapist. Moreover, a discussion was held about the newly provided content, and the therapist provided the necessary explanations to the couple to teach the concepts.

At the end of each session, a summary of the provided material was made by the therapists. After the training sessions, the experimental and control groups took a post-test under the same conditions. Furthermore, after the completion of the post-test phase, the control group received intensive reality therapy based on choice theory sessions for one week in order to observe ethical principles.

Subsequently, the collected data were analyzed in SPSS software (version 23) using the multivariate analysis of covariance. It should be noted that a p-value less than 0.05 was considered as statistically significant.

Thompson and Walker's Intimacy Scale (IS), which consists of 17 questions and designed to measure intimacy in couple relationships, was applied in the current study (18). The scores for each question vary from 1 (never) to 7 (always), with higher scores indicating more intimacy. This scale has a good internal consistency with a coefficient of 0.91-0.97 (19).

The score of each subject is obtained by adding the scores of the questions and dividing it by 17. In a study performed by Khodadadi Sang Deh et al. (2018), the validity of the marital intimacy scale was obtained as 0.78 and the reliability of this questionnaire was calculated at 0.89 using Cronbach's alpha (20). In the present study, the reliability of the marital intimacy scale was calculated at 0.87 using Cronbach's alpha.

ENRICH marital satisfaction inventory was developed by Olson, Fournier, and Druckman (1987) (21). The questionnaire consists of 12 subscales, namely "marital satisfaction", "idealistic distortion", "personality issues", " communication", "conflict resolution", "financial management", "leisure activities", "sexual relationship", "children and parenting", "family and friends", " equalitarian roles , "religious orientation".

In ENRICH marital satisfaction inventory, each item is scored on a five-point categorical scale ranked as 5=totally agree, 4= agree, 3= Neither agree nor disagree,,  2=disagree, and 1=totally disagree. Scores below 30 indicate extreme dissatisfaction with marital relationships, between 30-40=dissatisfaction, between 40-60=relative and moderate satisfaction, between 60-70=high satisfaction, and above 70=very high satisfaction (21).

The internal consistency of the questionnaire was reported to be 0.73 using Cronbach's alpha coefficient for all questions (22). In the present study, the internal consistency of the questionnaire was obtained at 0.87 using Cronbach's alpha coefficient. 

Reality therapy based on the choice theory was held in ten 60-minute sessions twice a week under the reality therapy based on Glaser's theory adapted from a study carried out by Amani (23). A summary of the reality therapy session based on the choice theory is presented in Table 1.

Results

This section provides a statistical description of demographic information; thereafter, the possible difference between groups in terms of research variables is examined in different stages of assessment. The following table presents the age, education, and occupation of the participants as assigned to experimental and control groups (Table 2).

     As illustrated by the results depicted in this table, the two groups are almost homogeneous in terms of the variables of age, education, and occupation.

     The results of the chi-square test also indicated that the difference between the two groups in terms of age, education, and occupation was not significant.  Accordingly, it can be stated that the two groups are identical in terms of these three variables (P˃ 0.05). Prior to analyzing the hypothesis-related data, they were examined to ensure that the data in this study can estimate the underlying assumptions of multivariate analysis of covariance (MANCOVA).

      To this end, the normality of the data using the Shapiro-Wilkes test demonstrated that the level of significance in the abovementioned test was reported as ˃0.05; therefore, the distribution of scores was normal in research variables (P ˃0.05). The homogeneity of variance results demonstrated that the significance level was obtained as ˃0.05 based on the Levene's test. Furthermore, equality and homogeneity existed between auxiliary and dependent variables at all levels of the agent (i.e., the experimental and control groups).

     Based on the homogeneity of regression, the significance level of the effect of group interaction and pretest was calculated at ˃0.05. Since the interaction between dependent and auxiliary variables (covariates) was not significant, homogeneity of regression was accepted for the research variables. In addition, since the correlation of auxiliary variables (pretests) was reported as ˂0.90 and according to the obtained correlations, the assumption of multiple lines between auxiliary variables was avoided.

     Table 3 demonstrates the mean and standard deviation of the research variables of experimental and control groups in pre-test and post-test.

    Thereafter, after the control of the effect of pre-test,  multivariate analysis of covariance was applied to determine the effect of reality therapy based on choice theory on marital intimacy and satisfaction to compare experimental and control groups based on post-test scores. The obtained results are displayed in Table 4.

  As demonstrated in Table 3, the statistical tests of multivariate analysis of covariance (MANCOVA) revealed significant differences between the experimental group who received reality therapy based on choice theory and the control group in terms of at least one of the dependent variables.

Table 4 shows the results of univariate covariance analysis for posttest scores in terms of dependent variables.

 As illustrated in Table 5, the F ratio of univariate analysis of covariance for dependent variables shows a significant difference between the experimental group who received reality therapy based on the choice theory and the control group regarding the variables of intimacy and marital satisfaction. Accordingly, the results are indicative of the effect of reality therapy based on the choice theory on intimacy and marital satisfaction in the post-test stage.

Discussion

     The present study aimed to investigate the effectiveness of reality therapy based on the choice theory in intimacy and marital satisfaction among couples referring to Ahwaz counseling centers. The results revealed that reality therapy based on the choice theory used in the present study could improve marital intimacy (P= 0.009; F= 7.40) among couples referring to Ahwaz counseling centers. This finding was consistent with the results of studies conducted by Zarei et al. (24), Sudani et al., and Aqa yoosofi et al (25).

   This result can be attributed to decreased external control and increased internal control which is encouraged in reality therapy based on choice theory, thereby discouraging people from controlling their spouses. When people try to control each other, they use more blaming methods against each other which leads to a considerable drop in their life satisfaction. On the other hand, self-control causes a significant decline in blame and criticism and improves life satisfaction (26).

     Consequently, the abovementioned factors bring success to reality therapy based on choice theory as an effective treatment for the improvement of marital intimacy and the reduction of marital conflict (27). Glasser's theory of choice puts more emphasis on love and intimacy in marital relationships, helping couples work their way back to a happy life. Moreover, it teaches people to avoid the seven deadly habits and replace them with the seven caring habits.

The choice theory emphasizes the acceptance of responsibility to fulfill your basic needs and those of your spouse and break free from external control. Therefore, the couples may not have devoted full attention to the needs of themselves and their spouses before the intervention. The fulfillment of each other's needs in a marital relationship is one of the key factors in improving couples' intimacy (28).

     Therefore, it can be argued that attending marriage enrichment training sessions based on choice theory has been able to draw couples’ attention to these important issues. Accordingly, they should consider these issues in their behaviors. Another important point is that marital intimacy needs time to flourish and requires couples’ understanding of each other's needs which is emphasized in choice theory. In general, the choice theory explains how we make choices to identify and balance our needs.

     Strengthening communication skills increases positive self-esteem and reduces negativity, which in turn, leads to increased psychological intimacy between couples (29). Moreover, the results suggested that reality therapy based on the choice theory used in the present study could improve marital satisfaction (P=0.001; F=22.73) among couples referring to Ahwaz counseling centers. This finding is in line with the results of studies conducted by Glasser (12), Disjani and Kharamin (30), and Amani (23).

     This finding can be justified on the ground that couples seeking a divorce are usually stuck in an unhappy, emotionally barren marriage and experience lower levels of marital quality (31). This can provide a source of emotional distress to couples. Spouses with poor marital relationships and low marital satisfaction usually experience many setbacks and are concerned about the future and success of their marriage (32). These couples also use ineffective coping skills to deal with problems, all of which lead to their frustration (33). Consequently, the level of happiness, optimism, and marital satisfaction tend to be low in these people (34).

     Reality therapy based on choice theory creates a receptive and supportive environment using such methods as a deferred judgment about therapy seekers, self-disclosure, attention to metaphors in the self-expression of therapy seekers, attention to topics, and summing up.  In so doing, it helps couples to formulate, clarify, and prioritize their perceptions of problems in order to change their behavior and thought (35).

In reality therapy based on choice theory, people with self-assessment shift their focus away from the behavior that is out of their control and focus on controllable aspects of behavior to reduce negative and dysfunctional emotions through positive, uplifting, and optimistic internal dialogue. Accordingly, one can develop a sense of empowerment and experience happiness (36-37).

     The current study has some limitations, such as the non-use of the follow-up stage. Therefore, caution should be exercised in generalizing the study results. The sample size was limited to couples referring to Ahwaz Counseling Centers. To overcome this limitation, it is suggested that similar studies be conducted in other cities and cultures. Yet another suggestion would be to use the follow-up phase to assess the sustained effectiveness of reality therapy based on choice theory.

     Furthermore, as evidenced by the obtained   results, it is suggested that reality therapy based on choice theory be incorporated into educational programs for couples and family therapy. In so doing, therapists can treat communication problems and enrich the intimate relationships of couples and families. It is also suggested that the effectiveness of this treatment approach be examined and compared in terms of such variables as the length of the marriage, gender, and the age of the subjects in future studies.

Conclusion

      The findings of this study indicate that reality therapy based on choice theory sessions is useful and practical in increasing marital intimacy and providing appropriate and efficient communication skills for couples that can lead to better marital satisfaction being established.

 Acknowledgements

     The current study was approved by the Ethics Committee of Islamic Azad University of Ahvaz with the code number of IR.AUS.REC.1398.6517323. It is noteworthy that all ethical considerations were observed in this study. The authors’ deepest appreciation goes to all participants who patiently helped us in different stages of the present research.

Conflicts of interest

Authors declared no conflicts of interest.